Substance misuse Flashcards
What are some substances that are commonly misused?
*ps how are they taken?
- Alcohol: oral
- Opiates (morphine): PO,IV, smoked
- Cannabis: PO, smoked
- Benzo: PO, IV
- stimulants (cocaine): IN, IV smoked, PO for others
- LSD: PO
- Aerosols: inhaled
- Anabolic: PO, IM
What are the ICD-10 criteria for substance misuse?
acute intoxication
harmful use
dependence syndrome
withdrawal state
psychotic disorder - within 2w, >48h
amnesiac syndrome
residual disorder - flashbacks, PD
What factors contribute to tolerance?
down regulation of receptors: cocaine is a dopamine reuptake inhibitor which increases dopamine firing, chronic firing leads to this
increased metabolism: alcohol inducing liver enzymes
Which factors may contribute to development of addiction?
genetic
neurobiological receptor modulation
dopaminergic effects
social patterns with others which then leads to solo problematic use
behavioural - operant conditioning
attachment - reduced opiate response in neglected children
dependence maintenance
What is important to cover in the history?
what - ‘when did you first try?’ ‘when did you feel like it became a problem?’
how long - focus on money
how much - per day or week
how often - cocaine binges
withdrawal - ‘how long since you last went without a drink for 3 days?’
Previous Tx, complications, overdose, tests and vaccinations (HIV, HEP)
social, PMH, living circumstances
What are some complications of substance misuse?
physical: death, infection, endocarditis, DVT, PE
psychological: cravings, anxiety, induced psychosis
social: crime, imprisonment, homelessness, relationship problems
What is the prevalence of alcohol misuse in the UK?
9 million drink over recommended limits
9% men and 4% women dependent
38% of homeless
What causes alcohol related mortality?
fights and falls
liver failure
pancreatitis
overdose - ometogenic and inhibits resp. centres and inhale vomit
withdrawal - delirium tremens
Wernickes encephalopathy
What are some concerning symptoms seen in an alcoholic?
head injury
confusion
shaking/ seizures
hallucinations
vomiting coffee grinds
severe abdo pain
sudden yellow
What factors show dependence in someone using alcohol?
- strong desire or sense of compulsion to take the substance
- difficulties in controlling substance-taking behaviour
- physiological withdrawal state
- evidence of tolerance
- progressive neglect of alternative pleasures or interests
- persisting with substance use despite clear evidence of overtly harmful consequences
What causes the symptoms of alcohol withdrawal?
brain compensates for the inhibitory effects of alcohol by increasing its activity to maintain homeostasis, which is seen as symptoms of withdrawal in its absence as brain remains hyperactive
What are some early symptoms of alcohol withdrawal?
tremor
sweating
nausea
anxiety
tachycardia
What are some late features of alcohol withdrawal?
delirium tremens
disorientation
hallucinations
tremor
BP, pulse, fever, motor incoordination
What’s the important thing to consider when referring someone to detox?
unprepared detox has very high relapse rate compared to a planned motivated detox
What is Wernicke’s encephalopathy?
*thiamine deficiency as alcohol destroys thiamine uptake
ataxia, nystagmus, ophthalmoplegia caused by midbrain haemorrhage
other features: vomiting, altered consciousness, fever, CN VI palsy
*Pabrinex
What is Korsakoff’s ?
permanent brain damage due to haemorrhage
impairment of recent and remote memory, recall preserved, impaired ability to learn new things
confabulation - not on purpose, makes plausible things as they don’t recall, slightly grandiose
How might you identify someone on opiates?
not very easily - only sign pin point pupils
- problematic
decreasing consciousness
slow breathing
death
How might opiate overdose be identified?
Loss of consciousness
Unresponsive to outside stimulus
Awake, but unable to talk
Breathing is very slow and shallow, erratic, or has stopped
Choking sounds
Vomiting
Body is very limp
Face is very pale or clammy
Fingernails and lips turn blue or purplish black
Pulse (heartbeat) is slow, erratic, or not there at all
How might opiate overdoses be managed?
there is time 90min-2hr average time from injecting overdose to death
AtoE
Naloxone: 400 micrograms every 2-3 mins IM in non-medical setting
How would you recognise opiate withdrawal?
early - sweaty, clammy skin, yawning, rhinorrhoea, tachycardia, restless, dilated pupils
late - N+V, diarrhoea, insomnia, muscle pains
Why is methadone useful?
less addictive as 1/2 life longer than 24h, no high as such as slowly enters system
gives people time to get support and move on
start on 30mg after withdrawal (positive reinforcement) titrate up
How is Buprenorphine useful in substance misuse?
tablet under tongue
partial agonist on mu-opioid receptor: high affinity so binds more tightly bound so heroin use has no effect, sends to withdrawal first then give to reduce effects
difficult to die on it, unless benzo or alcohol may cause
What is the difference between detox and rehab?
detox is the weaning off of the substance, done at home
*dangerous to detox opiates as mortality high // alcohol for 3m
rehab is a 6 month therapeutic community which uses psychology
What is important to know of benzodiazepine withdrawal?
hallucinations come earlier, may get turned away with psych referral
tachycardia and tremors come later with seizures too
*long half life, over 70h, used in withdrawal
How might benzodiazepine be problematic?
long half life
more difficult than heroin to treat
disinhibiting with alcohol
*reduce own supply, pregabalin has high street value
What effects do stimulants have?
increases work rate of heart
vasoconstrictor
increases BP
*acute MI, strokes due to haemorrhage
with alcohol reduced feeling of drunk so people engage in dangerous behaviour
worse on liver with alcohol
psychosis like
What is dual diagnosis?
substance misuse and mental health problems
- opiates are anti-psychotic
- stimulants psychoto-genic
- cannabis increases prevalence psychosis
- alcohol is a depresso-genic
